Rise Women's Legal Centre

516 Richards St.
Vancouver, BC
V6B 3A2

236-317-9000

VLC Request for Service Form

This form is for Community Partners to complete with their clients to request service through the Virtual Legal Clinic.

Please note that this intake form is different from the public request for service form on our website.

If you have any difficulties filling out this form, please email vlc@womenslegalcentre.ca.

Your information

Community/Support Worker Name:

Agency/Organization:

Community/Support Worker Phone:

Your Client's Information

IMPORTANT NOTE: For safety reasons, Rise will communicates with the community partner via email. In the email below, we ask you fill out your email and not the client's as all communication related to this form and the next steps will go through the email below.

Please only include the client's phone number if it is safe to do so.

CLIENT'S NAME: Rise considers the name an individual uses / refers themselves to as their primary/real name._{e.g. If client's legal name is "Jiamin Yang" but goes by "Jasmine Yang", please enter "Jasmine Yang". There will be a separate question for legal names.}

Contact information: Client Information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

If the client's legal name is different than above, please provide it here:

Client's pronouns

i.e. she/her/her; he/him/his; they/them/theirs

Client's place of birth

City or town; province/territory or state; country

What city does the client currently live in?

City or town; province/territory or state; country

Client's financial information

As Rise's services are free for clients, we will inquire about the client’s current assets, debts and sources of income at the navigation appointment with the Legal Navigator. This step is taken in order to assess to refer the client to the appropriate legal resources.

About how much income did you receive last month after taxes were deducted?

This is used to help Rise consider other programs and services that you may qualify for and to report aggregate data to funders (i.e. strictly confidential and NOT reported with any identifiers).

Aside from yourself, how many people depend on your income? Please include the relationship of each person to you.

(for example, child, step-child, parent, etc.).

Accessibility needs

As Rise Women's Legal Centre, we do our best to provide for the unique needs for our clients and are gathering the information below, so we can be best prepared to assist you with your needs.

The Virtual Legal Clinic provides services by phone and video chat. Do the client or you have any barriers that would prevent you from receiving services by phone and video conferencing? (e.g. impairments in hearing, vision, etc.).

Yes

Does the client need an interpreter?

Yes

DISCLOSURE TO THIS INFORMATION IS OPTIONAL. Please check all options that the client identifies with:

We ask you for this information for three reasons: (1) we want to be able to target specific resources that will serve the client best, (2) we collect and review information about our clients to ensure that we are meeting the needs of underserved groups, and (3) we are required to compile anonymous statistical info for reporting to our funders, However, we report general statistics only and we will NEVER give out any personal information about any of our individual clients.

Self-identifies as an Indigenous person

Yes

Self-identifies as a Black person

Yes

Self-identifies as a racialized person and/or person of colour

Yes

Self-identifies as a sex worker

Yes

Self-identifies as a person with a disability

Yes

Self-identifies as an English language learner

Yes

Self-identifies as an immigrant, refugee, and/or newcomer

Yes

Self-identifies as a Francophone

Yes

Self-identifies as non-binary, gender diverse, trans*, or 2 spirit

Yes

Self-identifies as LGBQ

Yes

Is there anything else the client would like to share about how they self-identify?

Opposing Party's Information

The only required fields are the first name, last name and the date of birth of the opposing party.

If there are more than one Opposing Party in the matter, there is place to record other names.

We are required to ask the client for this information so that we can conduct check for any conflict of interest. We will never contact this person without your knowledge and consent.

Note: We cannot move forward with an appointment with us without the client providing us this information.

Contact information: Opposing Party

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

If the opposing party ever uses a different name than the above, please provide it here:

Opposing Party's Date of Birth

If the opposing party's date of birth is unknown, type in "Don't Know". This cannot be left blank as it is a required field.

Name(s) of any additional Opposing Parties

Information about the legal matter

Please include a brief description. However, you do not have to include details here or details that you are not comfortable with sharing at this point. A brief description will help us send out follow-up navigation information forms based on what we need, and not ask for extra information that we do not reasonably need. Any information you provide will help us help you better.

The Virtual Legal Clinic is able to provide assistance with family law matters. If this is an immigration matter, please contact Immigration and Refugee Clinic (https://www.irlc.ca/)

In 2-3 sentences, please explain the client's legal problem:

Has the client or their children experienced family violence from the other party?

Family violence includes physical, financial, sexual, emotional and psychological abuse.

Does the client have Legal Aid or has applied for Legal Aid?

Add in information If the client has Legal Aid, and is looking for change of counsel, or extension of contract. Also, add in any information if the client was refused Legal Aid and is seeking legal aid advocacy.

Does the client have a lawyer?

Does the client have an upcoming court date? If yes, what is the court date for, and which court?

I certify that only the Community Partner's email is used in place of the client's email

Yes

Next steps:

To book a navigation appointment, please check the confirmation email after submission or go to http://bit.ly/vlcnavigator. If you do not receive a confirmation email, please check your spam folder.

If you would like to review the steps for the VLC intake process, please email smelnyk@womenslegalcentre.ca.